Claim CLM-2026002004
$51.54
billed
$36.08
allowed
$0.00
paid
$36.08
patient responsibility
Adjudication lines
| Service | Code | Billed | Paid |
|---|---|---|---|
| Amoxicillin 500 MG Oral Tablet | 308192 | $0.00 | $0.00 |
| Therapeutic injection/administration | 96372 | $35.47 | $24.83 |
| Service | Code | Billed | Paid |
|---|---|---|---|
| Amoxicillin 500 MG Oral Tablet | 308192 | $0.00 | $0.00 |
| Therapeutic injection/administration | 96372 | $35.47 | $24.83 |